Psychiatric Dispatches: Noteworthy Briefs from the Field: June 2007

Articles

Drug Abuse and Dependency Affects More Than 10% of Adults

Although drug use, abuse, and dependence are prevalent in the United States population and are associated with substantial costs to individuals and society, epidemiologic data on prevalence, correlates, disability, treatment, and comorbidity are seldom reported. While drug abuse refers to the intense desire to use drugs in place of participation in other activities, drug dependence refers to the body becoming dependant on an illicit substance.

According to a study by Wilson M. Compton, MD, MPE, at the National Institute on Drug Abuse (NIDA), and colleagues at the National Institute on Alcohol Abuse and Alcoholism (NIAAA) in Bethesda, Maryland, drug use or abuse has been reported in approximately 10.3% of American adults during their lifetimes, with 2.6% of those individuals becoming drug dependant at some point.

Data from in-person interviews with 49,093 adults that were conducted in 2001 and 2002 were used to determine the prevalence of abuse or dependence on nicotine, alcohol, or other classes of drugs. The drug classes used in the study included cannabis, cocaine, hallucinogens, heroin, inhalants/solvents, opiates (with the exclusion of heroin), sedatives, stimulants, and tranquilizers. Participants were also assessed for mood, anxiety, and personality disorders. Level of disability for those with drug use disorders was ranked on a scale of 0–100, with lower scores indicating greater disability.

According to participant reports, 1.4% abused and 0.6% were dependant on drugs during the previous 12 months. Lifetime rates included 7.7% for drug abuse and 2.6% for drug dependence. The average starting age was 19.9 years for drug abusers and 21.7 years for those who were dependant on drugs. Approximately 8.1% of drug abusers and 37.9% of those who were drug dependant received treatment at one point during their lives. Rates for both dependence and abuse were higher among males, Native Americans, adults 18–44 years of age, lower socioeconomic groups, people living on the West coast, and unmarried individuals. Drug abuse and dependence were also associated with alcohol use disorders; nicotine dependence; mood, anxiety, and personality disorders; and mental, social, and emotional disability.

Due to the early age-of-onset of both drug abuse and dependence, efforts to prevent, treat, and destigmatize would be ideal during the adolescent years of those at risk.

Funding for this study was provided by the Intramural Program of the National Institutes of Health, part of the NIAAA. The National Epidemiologic Survey on Alcohol and Related Conditions is funded by the NIAAA and the NIDA. (Arch Gen Psychiatry. 2007;64(5):566-576).—DC

US Military Forces Serving in Iraq Have Increased Prevalence of Mental Health Disorders

In May, the United States Department of Defense released the fourth set of findings from the Mental Health Advisory Team (MHAT-IV) survey assessing the mental health status and the well-being of the US military’s deployed forces in Iraq and examining the delivery of behavioral health care in Operation Iraqi Freedom.

In August and October of 2006, the researchers surveyed 1,320 soldiers and 447 Marines regarding their battlefield ethics. This was the first of the four surveys to evaluate and assess Marines. The soldiers and Marines surveyed were involved in combat operations in Iraq at the time of the survey and their units were selected based on high levels of combat exposure. The soldiers served in brigade combat teams and the Marines served in Regimental Combat Teams. In the soldiers population, 71% were deployed in Iraq for the first time and 29% had multiple deployments with an average deployment of 9 months. In the Marines population, 67% were deployed in Iraq for the first time and 33% had multiple deployments with an average deployment of 6 months.

The troops behavioral health status was assessed via the Soldier and Marine Well-Being Survey. Researchers found that 6% of Marines and 13% of soldiers were experiencing severe stress, emotional, alcohol, or family problems.

The MHAT-IV researchers found that 17% of soldiers and 14% of Marines suffered from acute stress; 9% of soldiers suffered from anxiety, compared to 5% of Marines; 9% of soldiers suffered from depression, compared to 4% of Marines. Overall, 20% of soldiers and 15% of Marines were suffering from a mental health problem. The authors noted that troops who were deployed for >6 months or were deployed multiple times were more likely to screen positive for a mental health issue.

They also found a direct correlation between mental stress and level of combat. For example, 30% of soldiers taking part in high combat (n=435), 17% of soldiers taking part in medium combat (n=452), and 11% of soldiers taking part in low combat (n=430) suffered from any mental health problem. In the Marine population, 30% of Marines taking part in high combat (n=124), 11% of Marines taking part in medium combat (n=136), and 7% of soldiers taking part in low combat (n=184) suffered from any mental health problem. The study did not define specific traits of combat.

The suicide rate amongst the soldiers was 17.3 per 100,000 soldiers. Although lower than the suicide rate reported in 2005 (19.9 per 100,000 soldiers), this rate is much higher than the current average of 11.6 per 100,000 soldiers overall for the US Army. Greater than 33% of respondents believed that torture should be allowed when attempting to save the live of a fellow soldier or Marine, and <50% stated they would report a team member for unethical behavior.

The findings suggest that multiple deployments as well as extended tours of duty can escalate anger, cause soldiers to “lash out” at civilians, and make members of the armed forces more apt to defy military ethics. The researchers recommend that, before re-deployment, troops should spend 18–36 months at home, rather than the current 12-month period.

The US military has already implemented a series of remedies to support these soldiers and Marines, including scenario-based battlefield ethics training, revised suicide prevention training, behavioral health awareness training, pre- and post-deployment small-group BATTLEMIND training to soldiers, Marines, and their spouses, and BATTLEMIND training for Warriors in Transition.

The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study—a 6-year, federally-funded study designed to emulate real world depression treatment—began with 2,876 patients of which one-third achieved remission. STAR*D participants were given the option of seeking second-step treatment alternatives when the initial treatment, citalopram, did not improve depression symptoms. An equipoise-stratified design allowed patients who did not achieve remission to include or exclude the second-step treatment options of cognitive-behavioral therapy (CBT) versus no CBT; any switch strategy versus any augmentation strategy; and medication switch strategy only versus medication augmentation strategy only.

Combined in one study, two reports separately evaluated patients’ willingness to accept second-step alternatives and the effectiveness of CBT for depression treatment, compared to pharmacotherapy. In the first report, Michael E. Thase, MD, of the University of Pittsburgh in Pennsylvania, and colleagues found that only 1% of the 1,439 patients who entered second-step treatment accepted all treatment strategies as options; 3% accepted only CBT, and 26% accepted CBT in conjunction with another treatment. Patients who were more educated or had a family history of mood disorders were more likely to view CBT with greater acceptance. The lack of serious side effects from CBT also motivated some patients to accept second-step treatment who either did not improve with citalopram, or who experienced a heavy side-effect burden from pharmacologic treatment.

Patients who accepted CBT as a second-step treatment, either alone or in conjunction with citalopram, had similar rates of remission and response as patients with a medication-only regimen, according to the second report. Citalopram treatment, augmented with CBT, resulted in a more rapid remission rate than with CBT alone, although both treatments had no significant differences in outcome. CBT is more widely tolerated than are antidepressants, and the authors noted that patients in primary care settings and with a greater side effect burden were more likely to choose a switch strategy as opposed to an augmentation strategy. (Am J Psychiatry. 2007;164(5):739-760).—LS

Although causal mechanisms are unclear, prior studies have linked symptoms of major depressive disorder (MDD) and other depressive disorders with a higher risk of developing diabetes. Specifically, research has shown that a single self-report of high depressive symptoms is associated with an increased risk of type 2 diabetes, which is a common health condition for patients ³65 years of age. A recent study sought to determine if depression is linked to diabetes prevalence for this age group.

Mercedes R. Carnethon, PhD, of the Department of Preventative Medicine at the Feinberg School of Medicine at Northwestern University in Chicago, Illinois, and colleagues, studied whether a single report of depressive symptoms were associated with the development of diabetes for 4,681 patients ³65 years of age. Patients in the study were evaluated over a 10-year period to assess diabetes development.

Participants diagnosed with diabetes were excluded from the study, however, those with risk factors for the condition were included. Patients from the Cardiovascular Health Study completed the 10-item Center for Epidemiological Studies-Depression Scale (CES-D) every year between 1989 and 1999. High depressive symptoms were defined as a CES-D score of ³8, while an increase in depressive symptoms was defined as a ≥5 point increase in CES-D scores from baseline measures. Persistent depression was defined as two consecutive reports of high depressive symptoms on the CES-D. Diabetes incidence was indicated by patients, who were not diagnosed with diabetes at baseline, initiating diabetes control medication during the study period. Researchers also assessed patient blood sugar levels at 2- and 4-year intervals as well as assessed body mass index, alcohol consumption, smoking, physical activity, C-reactive protein levels, and antidepressant use.

Carnethon and colleagues found that each measure of depression was significantly associated with diabetes incidence, and results were the same when the researchers controlled for race, gender, health, and lifestyle factors. The authors also found that patients who scored highest in depressive symptoms had a 50% greater chance of developing diabetes, when compared to patients with the lowest depression scores. While patients who were taking antidepressants showed lower incidence of developing diabetes, the authors said these findings could not determine if treating depression would reduce diabetes risk, as another cause could have reduced diabetes risk for these patients.

Carnethon and colleagues said biological factors, such as the autonomic nervous system, may link diabetes and depression, as prior studies have found that depression is associated with impairment in the autonomic system, which controls many involuntary bodily processes.

Although inflammation has also been associated with depression and diabetes, the study showed patient differences in inflammatory marker C-reactive protein levels had no affect on the connection between depression and diabetes. Study limitations included researchers not having clinical depression diagnoses for patients, reduced or estimated measures of physical activity, and data gathered from unreliable self-report measures.(Arch Intern Med. 2007;167(8):802-807).—CP

Prior studies have shown that major depressive disorder (MDD) and stress have a negative effect on the heart and blood vessel function. However, there has been inconsistent data on the effect of anxiety on the heart and cardiovascular system. Woldecherkos A. Shibeshi, MD, of Harvard Medical School in Boston, Massachusetts, and colleagues, evaluated the potential effect of anxiety on mortality and nonfatal myocardial infarction (MI) in pateints with coronary artery disease (CAD).

Five-hundred and sixteen patients with a diagnosis of CAD being treated at an outpatient cardiology clinic were evaluated during an average 3-year period. Patients (mean age=68 years) took the Keller Symptom Questionnaire annually to assess anxiety and the primary cardiovascular outcome measure included nonfatal MI or death due to any cause. The Keller Symptom Questionnaire assessed patients’ feeling during the previous week, including feelings of peace or anxiety, negative thoughts, or physical ailments, such as upset stomach.

Shibeshi and colleagues found that, during the study period of approximately 3 years, 44 patients suffered from nonfatal MI and 19 died. Among all patients in the study, the authors found that a high levels of anxiety were associated with an increased risk of nonfatal MI or death. This result remained the same after researchers controlled for age, gender, level of education attained, marital status, smoking, hypertension, diabetes mellitus, previous MI, body mass index, and cholesterol levels.

The researchers also found that patients whose levels of anxiety increased over time had the greatest risk of poor outcome due to cardiovascular causes or death, while patients who initially reported anxiety, but over time reported more peaceful feelings, reduced risk of MI or death. When patients were grouped by anxiety levels, those patients in the group with the highest anxiety levels had an almost double the risk of MI or death, when compared to patients who had the lowest prevlance of anxiety. Initial levels of anxiety also did not forecast future MI or death.

Shibeshi and colleagues concluded that increased anxiety among patients newly diagnosed with CAD is associated with risk of MI or death. The authors recommended that clinicians should spend additional time with patients who may be anxious and their families to better explain treatment options, including medication, and provide reassurance. Clinicians should also indicate that patients can benefit from increased exercise, and should reduce cardiovascular risk factors, such as having high blood pressure and cholesterol as well as smoking. The authors also suggested additional measures to assess patient anxiety. (J Am Coll Cardiol. 2007. In press.).—LS